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Massive weight loss following bariatric surgery is often accompanied by functional impairments due to the resulting excess skin and soft tissues. To achieve both functional reconstruction and restoration of the body silhouette, it is imperative to undergo body contouring surgery involving the strategic transposition of tissues. Several surgical techniques are available for the affected body regions and their application for treatment is determined by the unique circumstances specific to each patient. When conducted by skilled practitioners, postbariatric body reconstruction can be executed safely, leading to outcomes that are both functionally and esthetically satisfying, ultimately contributing to an enhanced quality of life for patients. This article provides the fundamental principles for patient selection, surgical preparation, treatment planning, surgical techniques and the postoperative care following bariatric surgery.

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PURPOSE: After metabolic and bariatric surgery (MBS), many patients have excess skin (ES), which can cause inconveniences. Identifying factors related to ES quantity and inconveniences is crucial to inform interventions. The aim of this study was to identify sociodemographic, physical, psychosocial, and behavioral factors associated with ES quantity and inconveniences. MATERIALS AND METHODS: A mixed-method study with a sequential explanatory design was conducted with 124 adults (92% women, Mage 46.5 ± 9.9 years, Mtime post-MBS 34.2 ± 27.6 months). During phase I, ES quantity (arms, abdomen, thighs) and inconveniences and sociodemographic, anthropometric, clinical, and behavioral outcomes were assessed. In phase II, 7 focus groups were performed with 37 participants from phase I. A triangulation protocol was completed to identify convergences, complementarities, and dissonances from quantitative and qualitative data. RESULTS: Quantitative data indicate only ES quantity on arms was associated with ES inconveniences on arms (r = .36, p < .01). Total ES quantity was associated with maximal body mass index (BMI) reached pre-MBS (r = .48, p < .05) and current BMI (r = .35, p < .05). Greater ES inconvenience was associated with higher social physique anxiety and age (R2 = .50, p < .01). Qualitative data were summarized into 4 themes: psychosocial experiences living with ES, physical ailments due to ES, essential support and unmet needs, and beliefs of ES quantity causes. CONCLUSION: Measured ES quantity is related to higher BMI, but not reported inconveniences. Greater self-reported ES quantity and inconveniences were associated with body image concerns.

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Excess skin after weight loss is perceived as a major problem for the majority of the bariatric patients, between 68 and 90% desire additional reconstructive surgery. However, only about 20% of the patients actually have the possibility to undergo these procedures. Reliable and valid patient-reported outcome instruments, PROM, are required in order to consider the patients' perspective of excess skin when discussing reconstructive surgery. The aim of this study was to present the updated version of Sahlgrenska Excess Skin Questionnaire, SESQ and to report on the validation process. The material for the process to evaluate internal consistency and known group validity was based on four different studies conducted at the Department of Plastic Surgery at Sahlgrenska University Hospital, Sweden. Internal consistency was high in all four groups examined; the normal population, the obese patients, the post-bariatric patients and the post-abdominoplasty patients. Values for Cronbach's alpha were >0.86 in all groups, and the highest value was seen in the obese patients (0.92). Furthermore, regarding known group validity, there were strong significant differences between the answers from the normal population in comparison with most of the other studies. In conclusion, patients thought that the questions in SESQ were easy to understand, that they covered all appropriate aspects of excess skin and the patients did not think that SESQ overlooked any questions or aspects concerning excess skin. SESQ is a valid questionnaire addressing excess skin in post-bariatric patients. The updated version of the SESQ is both accurate and user-friendly.

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The majority of post-bariatric patients suffer from excess skin after weight loss, impairing physical, psychosocial and mental health. The abdomen is the most common location for excess skin, and abdominoplasty is the most commonly required reconstructive procedure. Abdominoplasty removes excess abdominal skin and attenuates related symptoms, but knowledge regarding mental health-related effects is scarce. Here, we aimed to evaluate the symptoms and severity of depression before and after abdominoplasty in post-bariatric patients and to analyse the relationships between depressive symptoms, quality of life (QoL) and experience of excess skin. We enrolled 110 former obese patients undergoing abdominoplasty. Three questionnaires evaluating the symptoms of depression (Beck Depression Inventory (BDI-II)), experience of excess skin (Sahlgrenska Excess Skin Questionnaire (SESQ)) and QoL (36-item Short-Form Health Survey (SF-36)) were completed preoperatively and 1 year postoperatively. After abdominoplasty, symptoms of depression (BDI sum score) significantly decreased (5.8 vs. 3.0, p = .037). Scores on three BDI questions improved (p < .05), and the SESQ score normalised (p < .001), while the SF-36 score was unaffected. The BDI sum score was moderately correlated with the SF-36 mental composite score (preoperatively, rs = -0.69; postoperatively, rs = -0.66) and fairly correlated with the SF-36 physical composite score (rs = 0.32, rs = 0.26). The correlation between the BDI sum and SESQ scores was poor preoperatively (rs = -0.106) and fair postoperatively (rs = 0.232). The results indicate that abdominoplasty may reduce symptoms of depression in post-bariatric patients. However, the procedure did not affect SF-36 scores. Further studies are required to validate these results.

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BODY-Q is self-administered questionnaire that evaluates appearance, function and symptoms related to bariatric- and body contouring surgery. The purpose of this article was to describe the translation process of a Swedish version of BODY-Q and to evaluate its criterion validity to the Swedish questionnaire Sahlgrenska Excess Skin Questionnaire, SESQ. MATERIALS AND METHODS: BODY-Q was translated according to International Society for Pharmacoeconomics and Outcome Research's guidelines. The test of validity was made between parts which were comparable to SESQ. Both questionnaires were responded by 30 subjects who were suffering from excess skin after massive weight loss following bariatric surgery or dieting. RESULTS: The correlation between the two questionnaires varied. The parts of BODY-Q evaluating excess skin on the whole body and parts of the body had higher correlations (rs 0.328-0.766) than the parts evaluating side effects of excess skin and body-image (rs 0.103-0.574). CONCLUSION: The Swedish version of BODY-Q has a good criterion validity and can be recommended in the healthcare for patients with excess skin after massive weight loss and for evaluation of the outcomes from reconstructive surgical procedures.

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A common side effect after massive weight loss is excess skin. Knowledge about the experience of excess skin in relation to physical activity is limited. The aim of this study was therefore to investigate how post bariatric surgery patients experience physical activity in relation to excess skin. Fifteen semi-structured interviews were performed with individuals who experienced excess skin after massive weight loss after bariatric surgery. The interviews were transcribed, and data were analyzed by qualitative content analysis. An overall theme emerged, that the body was still a hindrance for physical activity but now because of excess skin. There were major changes in the participants' ability to be active after the weight loss, but there were still obstacles and some of them remained from the time when they were obese. The analysis resulted in three main categories containing the participants' knowledge about, changes in and wishes for physical activity after weight loss, factors that affected the ability and the role of mental processes. The result contributes to increased knowledge about post bariatric patients' experiences of excess skin in relation to physical activity. After weight loss, the body was still a hindrance for physical activity but now because of excess skin. As physical activity is important for general health, excess skin inhibiting physical activity ought to be an indicator for reconstructive surgery.

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INTRODUCTION: Western studies have explored post-bariatric patients concerning their views on excess skin and body contouring surgery (BCS), but Asian data were lacking. This study aims to investigate the experience of excess skin and attitude to BCS of a Chinese post-bariatric population. METHODS: A total of 210 Chinese patients who underwent bariatric surgery from March 2015 to September 2018 were cross-sectional studied using the Sahlgrenska Excess Skin Questionnaire and a study-specific questionnaire. RESULTS: The survey response rate was 61.4%. Most responders (78.2%) reported they had excess skin, and the most common sites were the abdomen (70.2%) and the upper arms (61.3%). Most responders (66.1%) reported being bothered by impaired health-related quality of life (HRQoL), and the most common problem was "the feeling of having unattractive body appearance" (42.7%). Many patients (37.9%) desired for BCS, and "the impact of excess skin is not serious enough" was the reason why not undergoing BCS being chosen most (28.1%), then "the cost is too high" (20.2%) and "worrying about the risk or complications of BCS" (18.4%). Younger age, female gender, higher weight loss, having full-time job, and earning higher income were independent factors increasing their desires for BCS. CONCLUSIONS: Most Chinese post-bariatric patients have excess skin and are bothered by impaired HRQoL. The abdomen and upper arms are the sites where patients are most seriously affected and most eager for BCS. The conservative attitude toward BCS and the cost without reimbursement are the main barriers.

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Excess skin and disordered eating behaviors are referred to as some of the major negative consequences of bariatric surgery as well as body image shame. This study sought to explore how discomfort with excessive skin, body image shame, psychological distress, eating-related psychopathology, and negative urgency interact to understand uncontrolled eating among woman submitted to bariatric surgery. A cross-sectional sample of 137 women was evaluated postoperatively through self-report questionnaires assessing discomfort with excess skin, body image shame, eating-related psychopathology, negative urgency, and uncontrolled eating in a hospital center in the north of Portugal. Pearson correlations and Structural Equation Modeling (SEM) were performed. Body image shame mediated the relationship between discomfort with excess skin and eating-related psychopathology. In turn, the relationship between eating-related psychopathology and uncontrolled eating was mediated by negative urgency. This study highlights the impact of excess skin and body image shame on eating behavior post-bariatric-surgery. Considering the proven impact of uncontrolled eating on weight-loss results post-surgery, understanding the mechanisms underlying this problem is highly important. Our findings provide helpful insight for multidisciplinary teams committed to providing care to bariatric patients struggling with body image and eating difficulties.

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BACKGROUND: The majority of postbariatric patients experience major problems from excess skin, with most desiring abdominoplasty. OBJECTIVES: To present visual assessments and objective measurements of excess abdominal skin; analyze relationships between patient-reported outcomes, objective measurements of excess skin, and visual assessments; and discuss criteria for reconstructive abdominal surgery in public healthcare. SETTING: An academic hospital in Sweden. METHODS: This is a secondary analysis of a prospective, longitudinal study that included 200 obese patients undergoing bariatric surgery, with 147 of these patients participating in follow-up 18-months postsurgery. Patients rated their symptoms related to excess skin and quality of life (QoL) according to the Sahlgrenska Excess Skin Questionnaire and EuroQol-5 D before and after bariatric surgery. Abdominal ptosis was measured at different anatomic locations. RESULTS: Waist circumference and ptosis were significantly reduced at all anatomic locations after weight loss, and abdominal ptosis was significantly larger laterally than at the midline (P < .001). The majority of patients had a ptosis ≥3 cm following bariatric surgery and had significantly more symptoms related to excess skin relative to those reported preoperation (P < .05). Additionally, the number of patients experiencing discomfort from excess skin increased along with increased ptosis size, but the correlation between ptosis size and QoL was low. Reconstructive abdominal surgery was requested by 70% of patients, all having significantly larger ptosis and significantly more symptoms than those not desiring surgery. CONCLUSION: Criteria for abdominal reconstruction should be based on both patient-reported symptoms and objective measures to ensure more patient-centered care than is possible only using objective measurements.

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Many post-bariatric patients have impaired health-related quality of life (HRQoL) due to excess skin following weight loss; however, it is inconclusive whether body contouring surgery (BCS) improves this impairment. We aimed to comprehensively summarize existing evidence of the effect of BCS on the HRQoL (primary outcome) and determine the prevalence of, the desire for, and barriers to BCS (secondary outcomes). Randomized controlled trials, cohort, cross-sectional, case-control, and longitudinal studies were systematically searched in PubMed, Embase, the Cochrane Central, and Web of Science. After screening 1923 potential records, 24 studies (representing 6867 participants) were deemed eligible. Only 18.5% of respondents from cross-sectional studies underwent BCS, with abdominal BCS as the most common procedure. Most participants desired BCS but listed "cost" and "lacking reimbursement" as the main barriers. Results suggest that most post-bariatric patients who underwent BCS experienced improvements in their HRQoL, which could be seen in almost every dimension evaluated, including body image and physical and psychosocial functions. Therefore, both bariatric and plastic surgeons should regard BCS not only as an aesthetic supplement but also as a vital part of functional recovery in the surgery-mediated weight loss journey and, thus, provide it to more post-bariatric patients.

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BACKGROUND: Bariatric surgery results in significant and durable weight loss and improved health in severely obese adolescents. An important adverse consequence of the massive weight loss after bariatric surgery is excess skin and soft tissue. The prevalence and clinical characteristics of excess skin-related symptoms have been described in adults undergoing bariatric surgery but not in adolescents. Although the higher skin elasticity of adolescents may result in fewer excess skin problems compared with adults, this hypothesis remains untested. OBJECTIVES: The purpose of the present study was to describe the natural history of excess skin and its associated complications among severely obese adolescents undergoing bariatric surgery. SETTING: University Hospitals, United States. METHODS: We evaluated data from the Teen-Longitudinal Assessment of Bariatric Surgery cohort, a prospective, multiinstitutional study of adolescents (13-19 yr) undergoing bariatric surgery. Abdominal pannus severity (graded 0-5) and excess skin symptoms were evaluated preoperatively and for the first 5 years after bariatric surgery. RESULTS: Among the 217 study participants, 198 (90%) had an abdominal pannus and 16 (7%) reported pannus-related symptoms at the time of bariatric surgery. Preoperative symptoms included intertriginous infections (n = 12, 75%), recurrent cellulitis (n = 5, 31%), and superficial cutaneous ulcerations (n = 1, 6%). Participants with a higher pannus grade preoperatively experienced both a greater reduction in pannus severity (P < .0001) and a higher incidence of pannus-related symptoms (P = .002) postoperatively. Changes in pannus severity occurred during the first 24 months after bariatric surgery; mean pannus severity remained unchanged beyond 24 months. CONCLUSIONS: Severely obese adolescents who undergo bariatric surgery often present with an abdominal pannus at the time of surgery with associated symptoms. Higher preoperative pannus grade is associated with more pannus related symptoms after surgery. Counseling about need for body contouring surgery should be considered in this group.

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BACKGROUND: Bariatric surgery leads to sustained weight loss and resolution of obesity-associated co-morbidities in severely obese adolescents. However, one consequence of massive weight loss is excess skin and soft tissue. Many details regarding the timing, outcomes, and barriers associated with body contouring surgery (BCS) in youth who have undergone bariatric surgery are unknown. OBJECTIVES: Describe the incidence and effect of BCS following bariatric surgery among adolescents. SETTING: University Hospitals. METHODS: Teen-Longitudinal Assessment of Bariatric Surgery is a prospective multi-institutional study of 242 adolescents who underwent bariatric surgery from 2007 to 2012. Utilization of BCS was analyzed in this population with comparison of anthropometrics and excess skin-related symptoms between those who did and those who did not undergo BCS. RESULTS: Among the 198 study participants with BCS data available, 25 (12.6%) underwent 41 body contouring procedures after bariatric surgery. The most common BCS was panniculectomy (n = 23). Presence of pannus-related symptoms at baseline and the magnitude of weight loss within the first year after bariatric surgery were independently associated with subsequent panniculectomy (P = .04 and P = .03, respectively). All adolescents who underwent panniculectomy experienced resolution of pannus-related symptoms. At 5 years after bariatric surgery, 74% of those who did not undergo panniculectomy reported an interest in the procedure, and 58% indicated that cost/insurance coverage was the barrier to obtaining BCS. CONCLUSION: Few adolescents who underwent bariatric surgery later underwent BCS procedures. Panniculectomy effectively treated pannus-related symptoms. Disparities in access to surgical care for adolescents who desire BCS warrants further investigation.

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BACKGROUND: Excess skin is well known after massive weight loss but, there is missing knowledge from various groups. OBJECTIVES: To describe and compare excess skin in a reference population during obesity, after obesity surgery, and after reconstructive abdominoplasty. SETTING: University hospital, Sweden. METHODS: The following 6 groups were included: the reference population, obese adults before obesity surgery, obese adults after obesity surgery, adolescents after obesity surgery, super-obese adults after obesity surgery, and adults after abdominoplasty. All groups filled in the Sahlgrenska Excess Skin Questionnaire (SESQ). Some groups also underwent measurements of ptosis/excess skin on 4 body parts. RESULTS: All groups scored significantly higher experience of and discomfort from excess skin compared with the reference population. SESQ scores were significantly higher for obese adults (10.5 ± 8.5) and even higher for adults and adolescents (12.3 ± 8.1 versus 14.4 ± 7.7) after obesity surgery compared with the reference population (1.5 ± 3.5). Abdominoplasty resulted in significantly reduced scores (2.9 ± 5.2). Those undergoing obesity surgery and weight loss had significantly less excess skin measured on arms, breasts, and abdomen compared with before surgery, except for the upper arms on the adolescents. Excess skin increased on inner thighs in both age groups after weight loss. Correlations between objectively measured ptosis/excess skin and the patients' experience of and discomfort were .16 to .71, and the highest correlations were found among adolescents. CONCLUSION: Excess skin is not a problem for the vast majority of the normal population but is linked to obesity and massive weight loss. The SESQ score illustrates major problems related to excess skin both for obese adults and after obesity surgery for adults and for adolescents, who have problems similar to or worse than adults. Abdominoplasty markedly decreases symptoms.

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The reconstruction of hallux varus deformity involves the release of contracted medial structure and realignment of the phalange, leaving a significant skin defect which requires cover. Farmer described proximal based rotational skin flap from the first web space to cover the defect. This technique may compromise the circulation to the flap and risk to the lateral digital vessels. We modified his technique to address these issues. We report a successful reconstruction using the Farmer's technique on one patient and a modified technique on three patients. We used the excess skin from the extra digit to cover the medial defect. We found this modified technique of skin cover safe without risk of injuring the neurovascular bundle. There was no recurrence of deformity at last foolow-up. All patients were able to wear normal shoes.

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@#The reconstruction of hallux varus deformity involves the release of contracted medial structure and realignment of the phalange, leaving a significant skin defect which requires cover. Farmer described proximal based rotational skin flap from the first web space to cover the defect. This technique may compromise the circulation to the flap and risk to the lateral digital vessels. We modified his technique to address these issues. We report a successful reconstruction using the Farmer’s technique on one patient and a modified technique on three patients. We used the excess skin from the extra digit to cover the medial defect. We found this modified technique of skin cover safe without risk of injuring the neurovascular bundle. There was no recurrence of deformity at last foolow-up. All patients were able to wear normal shoes.

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BACKGROUND: Bariatric surgery usually results in substantial weight loss and a reduction in medical comorbidities. Many patients, as a consequence of the weight loss, subsequently evidence loose, redundant skin. OBJECTIVES: This investigation seeks to examine the prevalence of body contouring surgery (BCS) by patients approximately 4 to 5 years after Roux-en-Y gastric bypass surgery. Demographics, change in BMI, and psychosocial variables were also used to predict body dissatisfaction, desire for BCS, and patients who reported obtaining BCS. SETTING: The clinical sites involved in the Longitudinal Assessment of Bariatric Surgery project, which included 10 hospitals across the United States. METHODS: The sample comprised 1159 patients who underwent Roux-en-Y gastric bypass and were enrolled in the Longitudinal Assessment of Bariatric Surgery-2 study. Participants were surveyed using the Excessive Skin Survey and other psychosocial measures at their 4- or 5-year postoperative outcome. The participants were predominately women (80.5%), Caucasian (88.3%), and middle-aged (mean = 46.1 yr, standard deviation = 11.11 yr). RESULTS: Participants reported modest degrees of being bothered by excessive skin, primarily in their waist/abdomen, thighs, and chest/breasts body areas. Only 11.2% of the sample had undergone any BCS procedure, and a majority of those participants paid "out of pocket" for BCS. Desire for BCS and body dissatisfaction 4 to 5 years postsurgery was associated with higher depression scores and poorer quality of life scores. CONCLUSIONS: Excessive skin is associated with poorer psychosocial functioning. Despite reporting modest levels of being bothered by excessive skin and body dissatisfaction, only a small fraction of participants underwent BCS. Cost of BCS was reported to be a primary barrier for not obtaining BCS. All rights reserved.

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Introduction: There is limited knowledge about self-image in relation to excess skin after bariatric surgery. The aim of this study was therefore to explore self-image after massive weight loss and its relationship to gender, weight loss, discomfort regarding excess skin and health-related quality of life. Methods: Eighteen months after obesity surgery, 131 patients filled in questionnaires about self-image (Som jag ser mig själv), excess skin (Sahlgrenska Excess Skin Questionnaire, SESQ) and quality of life (EQ-5D and SF-36). In addition, maximal ptosis was measured on their abdomen, arms and thighs. Results: There were no differences in self-image or quality of life between the genders. Participants who scored low discomfort on SESQ had a significantly better overall self-image, in all subscales, compared to those with high discomfort scores (p < .05). They also had a significantly higher quality of life on the EQ-5D VAS (p = .045). Correlations were low, if any, between self-image, excess skin, quality of life and ptosis. There were moderate correlations between the SESQ score and the self-image subscore 'physical well-being', and in self-image and quality-of-life scores. Conclusions: Self-image is lower among those who experience a high degree of discomfort of excess skin after bariatric surgery. Its correlation to weight loss, measured excess skin and quality of life is weak.

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BACKGROUND AND AIM: Even though health-related quality of life (HRQOL) is considered an important component of bariatric surgery outcome, there is a lack of HRQOL measures relevant for preoperative and postoperative patients. The objective of the current study was to develop a new instrument assessing HRQOL prior to and following bariatric surgery, entitled Quality of Life for Obesity Surgery (QOLOS) Questionnaire. METHODS: Topics for the QOLOS were initially generated via open-ended interviews and focus groups with 19 postoperative bariatric surgery patients. Qualitative analysis resulted in 250 items, which were rated by patients (n = 101) and experts (n = 69) in terms of their importance. A total of 120 items were retained for further evaluation and administered to 220 preoperative patients and 219 postoperative patients. They also completed a battery of other assessments to analyze issues of construct validity. RESULTS: Analyses resulted in a 36-item section 1 QOLOS form targeting both preoperative and postoperative aspects across seven domains (eating disturbances, physical functioning, body satisfaction, family support, social discrimination, positive activities, partnership) and a 20-item section 2 QOLOS form focusing on postoperative concerns only (domains: excess skin, eating adjustment, dumping, satisfaction with surgery). Subscales of both sections showed acceptable to excellent internal consistency (Cronbach's α 0.72 to 0.95) and good convergent and discriminant validity. CONCLUSION: The QOLOS represents a reliable and valid instrument to assess HRQOL in preoperative and postoperative patients. Future studies should test the questionnaire in larger samples consisting of patients undergoing different types of surgery.

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BACKGROUND: Little is known about excess skin in the normal population. The aim of this study was, therefore, to analyse the prevalence, impairments, and discomfort of excess skin in a cross-section of the Swedish population. METHODS: From the population registry of the Swedish Tax Agency, 1408 subjects living in Västra Götaland County from 18-59 years of age were randomly selected with an equal distribution of the sexes. Additionally, age was equally distributed, although twice as many subjects under 40 years of age were sent the questionnaire due to an expected low response rate for younger people. All subjects were asked to fill out the Sahlgrenska Excess Skin Questionnaire (SESQ), which included questions concerning the amount of and discomfort due to excess skin. RESULTS: No excess skin was reported by 78% of responders, including 71% of women and 87% of men. The responders who reported any excess skin were significantly older, had a higher body mass index (BMI) and reported larger differences between their maximum and current BMI. The most common reported site of excess skin was the abdomen in both women and men (26% and 8%, respectively), and this was reported to cause the most discomfort (median 4 and 2, respectively, on a scale from 0-10). Women graded psychosocial symptoms significantly higher than men, but there were no significant differences in other symptoms. CONCLUSIONS: The results indicate that Swedish adults, regardless of sex, do not suffer from excess skin and may be considered as reference values.

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BACKGROUND: Weight loss after obesity and pregnancy is associated with excess abdominal skin and weakness of the abdominal wall, which is assumed to cause low back pain and reduce lung function. Today, abdominoplasty is the only known method to treat excess skin, and plication is used to improve aesthetics and function alone or in addition to surgery. There is lack of evidence concerning the surgery's effect on trunk muscles, lung function, and physical function. The aim was to evaluate the effect on trunk muscle endurance, lung function and self-rated physical function after abdominoplasty with and without muscle plication. AIM: To evaluate the effect on trunk muscle endurance, lung function, and self-rated physical function after abdominoplasty with and without muscle plication. METHODS: A series of 125 people were randomised to abdominoplasty with or without rectus abdominis muscle plication. Trunk muscle endurance, lung function, and self-rated physical function (disability rating index) were measured before and 1 year after surgery. RESULTS: There were no significant differences in any of the measured variables between the groups either before or after surgery. A significant decrease (p = .02) in back muscle endurance was seen after abdominoplasty without muscle plication. A significant positive effect (p = .04) in one of the activities (running) assessed by DRI was reported after abdominoplasty with muscle plication. CONCLUSIONS: No significant differences in trunk muscle endurance, lung function, or self-rated physical function were found after abdominoplasty with vs without plication. As the primary indication for surgery was excess skin and not diastasis of the rectus abdominis muscles, there is a need for future trials before conclusions can be drawn of effect of abdominoplasty and plication.

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